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. 131I1 -- w <br /> City of Orono <br /> Building Permit Application <br /> —_� Mailing Address: Permit number. p�((��... <br /> ��O� CrOysBtal Bay, MN 55323-0066 Date received: �V c � / <br /> � � � <br /> �� �' � I Received by: <br /> a ,����. a,�� Street Address: <br /> ��ly���'�'G , <br /> 4� 2750 Kelfey Parkway Plan review fee: <br /> �kEsxo . Orono, MN 55356 <br /> , __-_-,.% Q�� � %� <br /> Total Fee: � � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �'L �-� � "{�Gt� ��I���f' �L Y��L� " <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service wi 1 be <br /> required unless applicanf demonsfrates sufficient on-site parking is available. Non-permitted events will not be a/lowed. <br /> CONTRACTOR/p�PPLICANT INFORMATION: <br /> Name: HYYI�'-Y'� � :�r l�t,;,�� � I� � ��,(1�1�C1G'"1rVd� ��'1C <br /> State License# 1 �(i� Expiration Date: 3j-�� - (7 �- <br /> Phone: C" " -`� - '� office cell <br /> Mailing Address: � p , i�t� � lCC' Cit : .(1�-�5�1 ZIP: <br /> Contact Persor�_ � ' G� l�E' �r� Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or'LFax: (. � ' ^ _ C �j <br /> PROPERTY OWNER INFORMATION; <br /> Name: '�1\Ctir' � �,lr���'\iC C�� <br /> Phone (day): ���� , >� - ^ — <br /> Address: ��� C'��'�-�G11 ('��� l�- 62�� City: ������' ZIP: �"J��b <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) � Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> Window ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> � Siding 8 Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 8 Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �'��i�tC,C��; � Sc�S4' e;5 �l� 1C� 3 I,� �V'��w�'1 �=5� <br /> Estimated Construction Valuation of Project(excluding land) $ ����,�.�'(�. DQ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information, the application may not be issued. <br /> ApplicanYs Signature: � G�,�'U-�� Date: �l�1�" D, r'v� <br /> Reset Form <br />